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A patient with hepatic encephalopathy is receiving lactulose. Which assessment provides the nurse with the best information to evaluate the patient’s therapeutic response to the drug?
- A. Stool color and character.
- B. Fingerstick glucose.
- C. Serum electrolytes and ammonia.
- D. Serum hepatic enzymes.
Correct Answer: C
Rationale: Lactulose reduces ammonia in hepatic encephalopathy by promoting its excretion. Monitoring serum ammonia and electrolytes (C) evaluates efficacy. Stool changes (A) are expected but not specific. Glucose (B) is unrelated. Hepatic enzymes (D) assess liver damage, not lactulose response.
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Before administering the evening dose of carbamazepine, the nurse notes that the patient’s morning carbamazepine level was 84 mcg/mL. What action should the nurse take?
- A. Notify the healthcare provider of the carbamazepine level.
- B. Administer the carbamazepine as prescribed.
- C. Withhold this dose of the carbamazepine.
- D. Assess the patient for side effects of carbamazepine.
Correct Answer: A
Rationale: Carbamazepine’s therapeutic range is 4-12 mcg/mL; 84 mcg/mL (A) indicates toxicity risk, requiring provider notification. Administering (B) or withholding (C) without consultation is unsafe. Assessing side effects (D) is secondary to reporting.
The nurse is administering sodium polystyrene sulfonate to a client with acute kidney injury (AKI). Which laboratory finding indicates that the medication has been effective?
- A. Serum potassium level of 3.8 mEq/L (3.8 mmol/L)
- B. Hemoglobin level of 13.5 g/dL (135 g/L).
- C. Serum glucose level of 120 mg/dL (6.7 mmol/L)
- D. Serum ammonia level of 30 Mcg/dL (17.62 Mermol/L)
Correct Answer: A
Rationale: Sodium polystyrene sulfonate treats hyperkalemia by exchanging sodium for potassium. A potassium level of 3.8 mEq/L (A) indicates effectiveness (normal range: 3.5-5.0 mEq/L). Hemoglobin (B), glucose (C), and ammonia (D) are unrelated to its action.
The nurse is planning care for a client with major depression who is receiving a new prescription for duloxetine. What information is most important for the nurse to obtain?
- A. Family history of mental illness.
- B. Weight change in the last month.
- C. Liver function laboratory results.
- D. Recent use of other antidepressants.
Correct Answer: C
Rationale: Duloxetine is metabolized by the liver, and impaired liver function can increase toxicity risk. Liver function tests (C) are critical before starting. Family history (A), weight changes (B), and other antidepressants (D) are relevant but secondary to liver safety.
A client with psychosis is receiving an antipsychotic medication and is continually rubbing the back of the neck. What is the best nursing intervention?
- A. Obtain an extra pillow for the client to use at night.
- B. Give a PRN prescription for benztropine.
- C. Provide the client a heating pad to place on the neck.
- D. Obtain a prescription for physical therapy services.
Correct Answer: B
Rationale: Neck rubbing suggests extrapyramidal symptoms (e.g., dystonia) from antipsychotics. Benztropine (B), an anticholinergic, relieves these symptoms. Pillows (A), heating pads (C), and physical therapy (D) don’t address the cause.
A female patient who follows a vegetarian diet has recently been prescribed warfarin. She mentions that she consumes leafy green vegetables daily. What should be the nurse’s response?
- A. Praise the patient for her healthy lifestyle and encourage her to maintain her current dietary habits.
- B. Assure the patient that her dietary choices will enhance the effectiveness of the medication in preventing blood clots.
- C. Inform the patient that her healthcare provider needs to be informed about her current diet.
- D. Recommend that the patient substitutes the leafy vegetables with a protein source like nuts or beans.
Correct Answer: C
Rationale: Leafy greens, high in vitamin K, can reduce warfarin’s anticoagulant effect. Informing the provider (C) ensures dose adjustment. Praising (A) or assuring enhanced efficacy (B) ignores the interaction. Substituting vegetables (D) is unnecessary with proper monitoring.